Question about patient with low back pain

[Willeseden]

Hi Folks,

I have only been practicing for a few months. I am having trouble sorting out one of my patients with low back pain.

History: 1.5 years of low back pain. Insidious onset. Reports that pain worsens with prolonged standing and is the worst in sidelying at night (supine is fine).

Observations: 25 year old male of medium build. Decreased lumbar and thoracic curves. Increased cervical lordosis with head forward posture. Decreased bulk in glute max R and L.

O/E:
ROM: lumbar is basically full but patient has increased pain with
extension and rotation/side flexion to both sides.
Neuroscan: is unremarkable.
Palpation: is very tender from L2 to S1 bilaterally along facets. Also
very tender over quadratus lumborum on both sides. No
increase in resting tone of hip external rotators.
Special testing: Much increase in pain with general lumbar torsion
test to both sides.
Diagnostic Imaging: None.

We have been working on core abdominal strengthening. He doesn't tolderate manual therapy well because of the tenderness. Manual traction has been helpful.

Any other treatment ideas?

What is the root problem?

Despite the lack of hard neuro signs, could this be disc involvement?

What are other possible pathologies?

Thanks!

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[wernerspine]

Ay stiffness in the morning?
Slump test positive?
does compresion of the head increases the pain?

Is the patient a drug user?
any psychological problems?
Is the injury a workers compensation?
ask the patient to do long sitting while lying supine in bed if the patient is able to do that discharge the patient. Also, try ultrasound I bet he will feel pain.
You are waisting your time with this patient.
good luck

[Willeseden]

Thanks for your reply.

This patient is actually a medical student, so I doubt he is malingering.

He has no morning stiffness. Slump test is negative.

He has decreased glute max girth bilaterally and tends to stand with his hips slightly extended.

[Gajba]

Hi!

Try extension in lying - check is it worse, better or same after TEN repetitions?
If it is better let us know!

Also try postural reeducation (in standing)...

Do you use Mulligan (NAGS/SNAGS) in your treatment?
It could be good for pain during rotation, but only if extension doesn't help.

Best wishes!

[smarak]

Has ankylosing spondylitis been exclued.Check what is HLA B27 report.
smarak

[neurospast]

1 you do not mention testing of the SI stability. SI tends to give multi segmental lumbar problems. In which position is the SI?
2 This seems to be a multi segmental problem.
3 Any radiation?
4 Kissing spine? since Pt has a more or less flattened + extended lumbar spine.
5 Bilateral, e.g. kidney involvement?
6 checked on thoracic mobility?
7 quadratus lumborum: triggerpoints?
8 on palpation any triggerpoints found?
9 Family history of e.g. RA, ankylosing spondylitis?

[bikash63]

Hi- I am Bikash, a practicing PT in India/Bangalore.
Your patient might have Acute disc bulge with spinal compression.Better to go with an MRI study done and followed by the good opinion of a Neuro Surgeon.
The treatment you can give is UST,TENS,IFT-Dipole vector field 15 mins and Manual Pelvic traction at recommended dose.This will definitely help.
But please be sure to be with either a Good Ortho or a Neuro Surgeon for better result and knowledge.Thanks.

[Sheherezade nights]

Hi everybody,:eek

I am a physiotherapist from Holland and I would like to
share my physiotherapy experiences with you, lovely colleagues.
Dear Willeseden be sure about HLA-B27 report as Smarak said. I think that your patient may have spondylitis ankylopoetica. Because this desease:
- begins slowly
- Mostly with a low back pain, 80%.
- man:woman = 4:1, possible 10:1
- symptoms begin 15-35 year
The symptoons at SI joint are:
-pain, sensitivity, pseudoradicular pattern
-muscle spasme or/and atrophy
-kyphosis, decreasing of thorax escursion
Ask him if he has eye irritation (iritis).Also ask about his family history.

Good luck!

[Willeseden]

Thank you all for your replies. The patient does not have a family history of AS. He is gonig to see his doctor for an xray to check for spinal abnormalities.

I tried extension and it makes him worse. The longer he is extended, the worse the pain gets. His thoracic spine is very stiff, but lower cervical spine is very mobile. He definitely prefers to sit with posterior pelvic rotation and lumbar flexion as it is most comfortable.

A few of you mentioned the possibility of disc involvement. My question is: can it be an injured disc if there is an absence of neuro signs?

[saphysio]

Slump sitting (as your patient prefers to sit) would probable increase his backpain if there is a disc prolapse or herniation as this position increase the amount of pressure on the disc.

However it is possible to have a disc prolapse or herniation without any positive neurological signs, it just depends on whether the injured disc is causing narrowing of the intervertebral foramen (pressing on the nerve root) or spinal canal (causing spinal stenosis) or none of the above. If there is no pressure on the spinal cord or nerve root then all neurological test will be negative.

[alophysio]

Hi.

All the above posts are interesting and relevant questions.

However, this patient case is screaming out to me as a classic active extension pattern. I will write quite strongly in this post only because i am almost 100% certain that i am right because i have seen this very same pattern many times before...

I do not think he has disc pain. I do not think AS.

From the sounds of it, i would be willing to bet he has overactive back extensors. He will tell you he is trying very hard to keep a "good posture". He will tell you that when he slouches, he feels better but it is "bad" for him to do so because you shouldn't slouch.

When he does his core exercises, i bet he is overactive in his posterior pelvic floor and finds it hard to do.

Active SLR with compression of his SIJ will make his legs feel very heavy - while supine, get him to lift one straight leg up at a time and get him to note the "heaviness". Then use your fingers/hands via his PSIS and compress them medially and repeat. He will report significant heaviness in his legs.

The treatment solution is firstly to get through to him that he needs a lordosis and kyphosis in his body. He may be trying too hard to matintain good posture. He is probably overactivating his posterior pelvic floor and utilising his IO instead of TrA. He needs to learn to relax. You will probably find flexion-type exercises help, especially since it is the only movement that doesn't hurt.

He probably has a lot of fear of flexion due to his medical training and everyone worrying about discs etc but everything you have posted so far says that extension is painful - why put him into more extension when he stands with his hips hyper extended and flat backed?

Once his muscle overactivity comes down, you will see his extension pain decrease. Co-ordination and progression of his core stability work without IO/EO or RA activation will be important as well as relaxation of the posterior pelvic floor.

I am probably not making sense as it is midnight here but i will summarise.

1. He is probably suffering from excessive compression of the L/S. Utilise flexion-based exercises and stretches.
2. Tenderness in the facets, poor response to manual therapy (Maitland and mackenzie mobes) is classic for this condition.
3. The patient needs to get his head around the fact that he himself is making things worse by trying to maintain extension.
4. Restore normal spinal curves
5. Co-ordinate core-stability properly and specifically without the posterior pelvic floor.
6. Read Peter O'Sullivan's chapter in Grieve's Modern Manual Therapy or his Nov 2005 Masterclass article in Manual Therapy.
Link=www.sciencedirect.com/sci...e89ed9d8ae

I apologise for being so strong on this matter but I am almost 100% sure i am right...

Thanks for reading this far! I hope i didn't offend anyone.

[arkesh_physio]

try out with gr-2 central PA 4 restricted extn & pain,gr-2 lateral PA for side flxn.make sure 2 reproduce the same pain during the session of manual therapy.
for pain relief try out-ultra reiz current or tens-neuralgia mode followed by traction in extn-prone posn.

[alophysio]

Hi.

Why do people keep suggestion extension for this patient when clearly extension makes the patient worse (ext, SF and Rot in standing all occur in extension at the lumbar spine).

Why do we want to keep putting him into pain provoking positions? He is already not tolerating manual therapy using PAs.

[arkesh_physio]

i suspect a discal bulge compressing the iv foramen bcz traction is relieving the pain.

in old cases of discal bulge with fibrosis, extn may be painful bcz it further compresses the already compressed postr structures.due 2 this the lordosis could be decreased.
i dont think the spinal extensors can be tight bcz the lordosis is decreased.
prolonged flxn exs can further harm it ,whereas extn may not improve it but will certainly not harm it,
so i suggest u 2 continue tracn and go 4 an MRI to be sure.

[alophysio]

Hi.

A number of things.

Firstly, I don't think it is a nerve root problem because slump testing is negative. Neuro testing is negative. Flexion *relieves* the pain. Extension and LF and Rot make the pain worse. Also, the facet joints along the whole L/S are sore. This is not what you would expect from a disc bulge onto a nerve root.

Secondly, he is 25y.o. He would not have a fibrosed disc yet, especially without any history of trauma.

Thirdly, I did not say the spinal extensors are tight. I said they were overactive. A very important distinction should be made there. They can still be overactive with his decreased lordosis because he is probably co-contracting with his abodominals - probably external obliques. He is already overactive in his QL. His decreased bulk in the gluts is probably because he is hamstring dominant in his extension strategy.

Fourth, Extension can harm this patient. His spine is already in a compressed state. Further compression of these structures can cause sclerosis, spondyloslithesis, facet joint arthritis, disc problems, etc. Again i ask, why subject him to painful positions when his body is telling him flexion is the best place for relief.

Traction helps to decompress and relax the overactive muscles and joints. If you told him to hang from a bar, it would do the same thing.

I would still recommend that teaching how to have a relaxed posture with restoration of his spinal curves and activating his core muscles without global muscle activiation is the way to go. What i have written in this post is from learning this material from Peter O'Sullivan, Diane Lee, LJ Lee, Barbara Hungerford, Trish Wisbey-Roth, etc. Peter O'Sullivan's work on this exact type of problem has been sensational and the results in my clinic tell the story...

Lastly, electro is not going to solve his problem...

What do others think? Am I way off beam?

[ramleo]

Hi guys,

I am a sports training and physiotherapist from India. I agree with what alophysio is saying. We need get into the root of the problem. Using electrotherapy would only relieve you of the symptoms, but the problem would come back. Core training for this individual is very important, with attention to be focused on TA(transverse abdominus) and gluts tightening, as it will prevent instability while doing exercise and prevent further damage to the back. Flexion exercises can be done, but with care. Maybe we can check for gluts and hamstrings tighening also ans stretch it if needed. I hope i made some sense, as it is my first post.

Cheers.

[sdkashif]

Your patient seems to suffer from chronic back pain - Pain with onset > 3 months
5% of patients with low back pain
85% of costs due to loss of work and compensation
50% have clear structural diagnosis made for cause of their back pain

Your history is non contributory; provide a detailed history and rule out any red flags. These are

Weight loss, fever
History of cancer, exposure to TB, IV drug abuse
Age > 50
Adenopathy
Neurological symptoms

uni/bilateral
urinary retention
saddle anesthesia
Writhing in pain
(visceral/vascular)
Unrelenting pain at rest
(infection/ malignancy)

Do some additional tests for Physical examination briefing of which is as under:

Inspection

Posture
shoulders and pelvis level
normal lordotic/kyphotic curve present
Skin abnormalities
Gait

Palpation

Skin temperature
Bony contours
Soft Tissue contours
Local tenderness

Range of motion

Flexion (> 60 degrees*)
Schober's test
floor-to-finger measurement
Extension (> 25 degrees*)
Lateral Bending (> 25 degrees*)
Rotation
*values for which no disability would be assigned

Neurologic examination

Motor
Sensory
DTRs
Pathologic reflexes
Cord levels (Motor, sensation and reflexes)

Special tests

Straight leg raising With the knee extended and the patient supine or seated. the hip is flexed (with the leg straight). A positive test results in pain ln the sciatic nerve distribution and suggests a disc herniation

Lasegue's test(Bragard's test) Flexion of the affected limb's hip is not painful, but extension of the knee while the hip is flexed is painful. Such pain would indicate sciatica and spinal cord nerve root compression

Cross leg (Well leg) raising

Milgram test A test which usually confirms pathology either inside or outside the spinal cord sheath. The test is performed with the patient supine while both limbs are held straight out with the heels two to three inches from the table for at least 30 seconds. The test increases subarachnoid pressure and is positive when the patient is unable to hold the position for 30 seconds without pain, indicating pathology within or outside the spinal cord sheath, such as a herniated disc.


Valsalva


Pelvic Rock

Gaenslen (Indications: Evaluation for Sacroiliac joint disease
Sacroiliitis in Ankylosing Spondylitis. Technique: Passive Thigh Hyperextension. Patient lies supine. Fix lumbar spine against table (eliminates lordosis). Patient flexes hip and knee on affected side. Patient holds knee with both hands.Examiner hyperextends opposite thigh over side of table. Interpretation: Positive Test.Pain on thigh hyperextension suggests sacroiliitis

Patrick or FABER test Background: FABER Mnemonic
Flexion,ABduction, External Rotation.
Indications: Evaluation for Sacroiliac joint disease
Sacroiliitis in Ankylosing Spondylitis
Technique: External Hip Rotation
Patient lies supine
Knee on affected side flexed to 90 degrees
Foot on affected side rests on opposite knee
Examiner places one hand on opposite iliac crest
Stabilizes pelvis against table
Examiner places one hand on knee of affected side
Examiner externally rotates hip on affected side
Knee pushed laterally and down
Interpretation: Positive Test (Patrick's Sign)
Pain on external hip rotation suggests sacroiliitis

Abdominopelvic examination

Special tests
Nonorganic Back Pain

"Nonorganic signs should form part of a routine preoperative screen to help
identify patients who require detailed psychosocial assessment."
"Waddell's Signs"

3 or more considered clinically significant

Superficial (skin roll) tenderness
Nonanatomic Pain
Axial loading that increases pain
Rotation to 30 degrees that increases pain
Lasegue's test (distracted SLR)
Give-way weakness
Non-radicular sensory changes
Over-reaction


Rule out the Differentials of Back Pain

Musculoskeletal

Multifactorial
"Mechanical"
Degenerative Joint Disease (Facets)
Degenerative Disc Disease
Muscular Strain and Spasm
Better with rest, worse with activity
May have antecedent trauma

Radiculopathy

Herniated Nucleus Pulposis (HNP)
L4-S1 in 95% of cases of radiculopathy
L2-4 in 2-5%
75% of those with cauda equina syndrome have saddle anesthesia
L5 radiculopathy
pain/dysesthesia in posterior thigh and anterolateral leg
foot drop with weakness on dorsiflexion
S1 radiculopathy
pain/dysesthesia in posterior thigh and leg, posterior lateral foot
weak plantarflexion
decreased Achilles reflex

Compression Fracture

Acute, severe onset of focal pain
Elderly, prednisone therapy and SLE predispose
Pain will resolve spontaneously in 3-6 months

Inflammatory Back Disease

Examples
Ankylosing Spondylitis
Reiter's Syndrome
Arthritis of Inflammatory Bowel Disease
Psoriatic Arthritis
Morning stiffness
Symptoms better with activity, worse with rest
Young person (< 40)

Visceral/Vascular

Abdominal Aortic Aneurysm (AAA)
Perforating duodenal/gastric ulcer
Pancreatitis
Endometrial disease
Ovarian disease

Spinal Stenosis

Types
Degenerative (seen in elderly; most common)
congenital
Pseudoclaudication/Neurogenic claudication
Better with flexion of back
Bilateral neurologic deficits
Wide-base gait

Infection

Mycobacterium Tuberculosis (Pott's Disease)
Paravertebral Abscess
Intervertebral discitis or osteomyelitis
Herpes Zoster
Pyelonephritis
Endocarditis

Malignancy

"Primary"
Multiple Myeloma
Lymphoma
Pancreatic
Metastatic
Prostate
Breast
Renal Cell
Thyroid
Lung
Colon

Spondylolisthesis/Spondylolysis

Others

Hip disease
Spondylolisthesis/Spondylolysis
Scoliosis
Leg-length discrepancy
Scheuerman's disease
Fibromyalgia
DIS
Diabetic radiculopathy


Your patient seems to suffer from chronic back pain with posterior element pain. Pain which is worsened by increasing the lumbar lordosis, standing and walking is called posterior element pain. Posterior element pain is eased by maintained forward flexion, sitting, hip flexion ( with or without knee extended). Patients who have structural or postural hyperlordosis, who have facet arthropathy, and who suffer from foraminal stenosis show feature of posterior element pain. Pain from extension and rotation are usually of facet origion. Flexion treatment frequently improve the facet disease, spondylolysis, flexion dysfunction and certain types of derangement. Prescription of hyperextension exercises may make the condition worse. The goal of exercises should be to improve the abdominal strength and flexibility. As the hamstring muscles are often tight, so the stretching exercises for the hamstrings should also be emphasized. Pelvic tilt exercises also help to reduce any postural component causing increased lumbar lordosis. Myofascial release may also play a role in reducing pain from the surrounding soft tissues.

The role of bracing for reducing the pain of acute spondylolysis is controversial. The most commonly prescribed braces are thoracolumosacral spinal orthosis (TLSO) or modified Boston Brace.

The use of modalities can be given. These are used in isolation or in combination therapy according to the experience of the therapist. Superficial heating methods like Infra reds, electrical heating pads, moist heat pads & deep heating methods like Short wave Diathermy, Microwave Diathermy, ultra sound therapy & electrical stimulation like TENS, Interferential, high voltage pulsed current generators and diadynamic currents all can be used accoring to individual choice and case selections.

So advice about the spinal flexion exercises, bicycling and walking on sloped treadmill will improve the condition of patient. Patient should be restricted from the provocative activities that increase pain. Activities and exercises that reduces the extension stress are helpful in reducing pain especially in the acute episodes

[neurospast]

It is now 3 months after the discussion started and I am curious if we have helped Willeseden. Has his patient improved with all the suggestions made or is it none the better? Summarising general opinion: Extension exercises and/or posture no go zone. Disc problems unlikely. Ankylosing spondylitis was possibility. Some form of extension syndrome.
If it is none the better one tends to think of a none biological problem or a problem with internal organs so no musculoskeletal background.
By the way, sdkashif, Laseque is the person who came up with SLR. These are no separate tests.
I think it would be good practice if people asking for a advice about a patient would give feedback if the patient has improved or not and why (difficult to answer, but can focus the mind) as well what actions have been undertaken.

[sdkashif]

The physio clinician should certainly feedback us about the progress of their patients so that suggested treatment methodology adapted could be verified as in the case of Willeseden patient. But he has not fed back us about the progress of his patient. Any how not all the patients continue the treatment regimens and some times they seek other clinicians for treatment and that could be the possible drawback with the continued regimen adopted.

[Willeseden]

Sorry for not following up on this patient. I was recently on holidays. I ended up finding some instability of L4 on L5 with clinical testing and sent the patient to his doctor to order an xray. It turns out that the patient had a spondylolisthesis of L4 on L5 (grade 2). I focussed treatment on core stability (neutral and flexion exercises) as well as mobilising his stiff R hip to take some of the strain off the low back.
He is now asymptomatic. The thing I found tricky was that he had no real dural signs despite the listhesis. His dislike for extension makes sense due to his listhesis. Thanks for all your feedback.

Willeseden